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Vertebral Osteomyelitis

About 1% to 2% of children and adolescents with osteomyelitis have the infection localized to their spine. Within the spine, the lumbosacral area is the most common followed by the thoracolumbar region. There is a peak incidence in adolescence. Common presenting symptoms include back pain which can be severe, muscle spasm, vertebral tenderness, and fever (1). Patients may limp or refuse to walk, and usually appear quite ill, but may have had insidious symptoms for several weeks to months (63). Most will have an elevated ESR and white blood count. Blood cultures are positive in only slightly more than half of the patients. When an organism is detected, the most common organism is Staphylococcus aureus. Rare causes include Bartonella henselae and Salmonella species, and in patients from developing countries, tuberculosis is a major cause. Radiographs can often be normal in early vertebral osteomyelitis; therefore, if suspicion is high, bone scinti-graphy and/or MRI should be done (1,63). Treatment with antibiotics is usually successful, especially if a bone aspiration or biopsy identifies the causative organism, although there may be permanent bony defects.

Discitis

Discitis can present with many of the same features found with vertebral osteomyelitis but is more common in younger children (<5 years of age). However, a history of intravenous drug abuse in the adolescent increases the risk in this age group (63,64). Over 80% of cases involve the lumbar spine, generally L3/4 or L4/5 (1,64). The patient may refuse to walk, bend forward, or sit, and may present with back stiffness, malaise, poor appetite, muscle weakness, or hyporeflexia. Teenagers often have localized back pain that radiates to the buttocks and legs (44). Patients tend to have symptoms for several weeks, and most do not have fever or appear ill. The ESR, and often the white blood count, is elevated; the CRP is normal in the majority of patients (63,64). Varying frequencies of positive cultures from direct biopsy samples have been reported (0-88%) but only a minority of blood cultures have been positive (63,64). S. aureus is the most common etiologic agent when an organism is isolated (1,65). As it may take 2-3 weeks for radiographs to show disc space narrowing and vertebral end plate irregularity, MRI is considered the preferred imaging method (1,44). MRI also allows discitis to be distinguished from osteomyelitis and epidural abscess, both of which need to be treated more emergently (44). Treatment with intravenous antibiotics has been reported to lead to a faster and more complete recovery, but since many patients recover without antibiotic treatment, this is controversial unless there is a history of intravenous drug abuse (64).

Epidural Abscess

Although an epidural abscess can cause back pain, fever, and symptoms similar to those seen in patients with discitis or osteomyelitis, it is rare in the pediatric patient. Even in adults, there is usually an associated risk factor such as diabetes mellitus, intravenous drug abuse, alcoholism, skin infections, or spinal trauma (66). About 12% of the cases are pediatric patients, with males older than 10 years the most likely to be affected (66). About one-third of cases occur in the lumbar or lumbosacral region, another third in the thoracic region. Irritability, back pain, localized tenderness, and neurological signs such as muscle weakness, incontinence, or paraparesis/ paraplegia are common symptoms (66). These symptoms can be acute or chronic, making diagnosis difficult (1). Most patients will have fever and an elevated ESR and white blood count. Epidural abscess is a medical and surgical emergency, since delay in treatment often leads to irreversible neurological residua or even death (1). MRI is the best imaging method (44). Surgical drainage and antibiotics are required, and again S. aureus is the most common pathogen (66).

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